UPWARD BOUND. New Student Application

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1 Western Michigan University UPWARD BOUND New Student Application Federal TRiO Program Funded by the U.S. Department of Education Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 1

2 Upward Bound Program Application Western Michigan University- Upward Bound Program Division of Multicultural Affairs 1903 W Michigan Ave Kalamazoo MI Phone: (269) Fax: (269) Please be advised. In order to be considered as a candidate for the Upward Bound Program the following information must be attached to Application Packet upon submission. Failure to comply will result in denial of application. Once you have attached the following information please check off the items listed below and sign your name verifying that these items are attached. Tax forms/income Verification Most Recent Report Card Recent Transcript MEAP/SAT Scores Recommendation #1 (can be found in your Student Application Packet) Recommendation #2 (can be found in your Student Application Packet) Record Release Form Student Name: Parent or Guardant Signature: Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 2

3 Please note that all applications are accepted for review regardless of race, color, national origin, religion, gender or disability (U.S. Dept. of Education -GEPA Section 427). Upward Bound Program Application DIRECTIONS: Western Michigan University- Upward Bound Program Division of Multicultural Affairs 1903 W Michigan Ave Kalamazoo MI Phone: (269) Fax: (269) Print clearly in ink. Be sure to answer all questions. Remember your parent/guardian s signature is required. Please submit your completed application directly to your school representative: ( Representative Name) PART I - STUDENT APPLICANT INFORMATION Date: Name: Social Security#: School ID #: Address: School Currently Attending: Current Grade Level: Mailing Address: Street and Apt. No. City State Zip Home Phone Number: Alternative Phone Number: Date of Birth: Age: Gender: Male Female Citizenship: Are you a U.S. Citizen? YES NO If NO Are you a Permanent Resident? YES NO r: Ethnic Background: African American or Black American Indian Asian/Pacific Islander Hispanic/Latino White More than one race Other Who do you live with? Mother & Father Father Mother Guardian Other Name of Guardian if you do not live with one of your parents: blac Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 3

4 What language is spoken at home? English Spanish Other What are you favorite school subjects? What grades do you usually get? What college or university do you plan to attend? Undecided What kind of career or job would you like to have? What do you plan on majoring in? Undecided What How did grades you find do you out usually about Upward get? Bound? Undecided Undecided What type of degree do you plan to obtain? You can check more than one. High School Diploma Vocational or Technical School Degree Two Year/Associate Degree 4 Year College Degree Masters Degree Doctoral Degree List any extracurricular activities are you involved in? Do you work or plan to work this school year and/or this summer? Yes No If Yes, when? Where? How many hours a week? Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 4

5 Personal Essay The personal essay is an important part of the selection process. In a 250 or more word essay discuss ONE of the following topics: 1) Events and persons in your background that have influenced you in your educational and professional aspirations; OR 2) Your purpose in applying to Upward Bound Program, what you believe you will attain from the experience, and the contributions you can make to the program; OR 3) your most impressive accomplishment and how it has impacted you. Please attach additional pages if necessary. Please give the attached Recommendation Forms to at least two (2) teachers or counselors at your high school. Remind your teacher(s)/counselor(s) to mail or fax these forms to our office as soon as possible. They can also return completed Recommendation Forms to you in a sealed envelope to submit with this application. Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 5

6 PART II RECOMMENDATION FORMS (To be completed by a Teacher) Western Michigan University Upward Bound Program Division of Multicultural Affairs 1903 W Michigan Ave Kalamazoo MI Phone: (269) Fax: (269) Dear Teacher: Teacher Recommendation Form The student listed below is applying for admission into the Upward Bound (UB) Project of Western Michigan University. Your assessment of the student s conduct, character and academic need for program services is an integral element in the admission process. Please give us your honest assessment of this student s desire and ability to learn. Please deliver the completed Recommendation Form to your school s WMU Upward Bound representative. You may also return the completed Recommendation Form to the student in a sealed envelope to submit with his/her completed student application. Should you have any questions or concerns, please feel free to contact your school s WMU Upward Bound representative. The time and effort you have taken to complete this form is sincerely appreciated. Student s Name Grade Level School Class/Course Subject: Current Class/Course Grade Please place an "x" in the appropriate column for each characteristic listed below: STUDENT CHARACTERISTICS EXCELLENT AVERAGE FAIR POOR CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME STUDY SKILLS/HABITS ANALYTICAL THINKING SKILLS MATURITY/INTEGRITY PUNCTUALITY EAGER TO LEARN NEW THINGS/INIATIVE DEMONSTRATES MOTIVATION TO COMPLETE A 6-WEEK SUMMER PROGRAM Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student s performance in Upward Bound. Additional comments may be written on the back. Teacher s Printed Name & Title School Telephone Number Teacher s Signature Date The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 6

7 PART II RECOMMENDATION FORMS (To be completed by Teacher or Counselor) Western Michigan University Upward Bound Program Division of Multicultural Affairs 1903 W Michigan Ave Kalamazoo MI Phone: (269) Fax: (269) Dear Teacher/Counselor: Teacher/Counselor Recommendation Form The student listed below is applying for admission into the Upward Bound (UB) Project of Western Michigan University. Your assessment of the student s conduct, character and academic need for program services is an integral element in the admission process. Please give us your honest assessment of this student s desire and ability to learn. Please deliver the completed Recommendation Form to your school s WMU Upward Bound representative. You may also return the completed Recommendation Form to the student in a sealed envelope to submit with his/her completed student application. Should you have any questions or concerns, please feel free to contact your school s WMU Upward Bound representative. The time and effort you have taken to complete this form is sincerely appreciated. Student s Name Grade Level School Class/Course Subject: Current Class/Course Grade Please place an "x" in the appropriate column for each characteristic listed below: STUDENT CHARACTERISTICS EXCELLENT AVERAGE FAIR POOR CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME STUDY SKILLS/HABITS ANALYTICAL THINKING SKILLS MATURITY/INTEGRITY PUNCTUALITY EAGER TO LEARN NEW THINGS/INIATIVE DEMONSTRATES MOTIVATION TO COMPLETE A 6-WEEK SUMMER PROGRAM Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student s performance in Upward Bound. Additional comments may be written on the back. Teacher s/counselor s Printed Name & Title School Telephone Number Teacher s/counselor s Signature Date The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g., are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 7

8 PART III UB Parent Application (To Be Completed by Parent/Guardian): Dear Parent/Guardian: Western Michigan University Upward Bound Program Division of Multicultural Affairs 1903 W Michigan Ave Kalamazoo MI Phone: (269) Fax: (269) Your child has indicated an interest in the Upward Bound (UB) Project of Western Michigan University. Upward Bound (UB) is a free college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by Western Michigan University. UB is specifically designed to strengthen the academic skills of eligible high school students to excel academically and pursue postsecondary degrees after high school graduation. Year-round services provided by UB include: Tutorial services during the school year to strengthen academic skills and prepare student for success at the college level: A 6-week summer instructional component that is designed to simulate a college-going experience that includes daily coursework in math and science as well as other related activities such as field trips and special events; Academic advising from UB staff and individual assistance with the college admissions and financial aid application process during the academic school year. In order to comply with federal regulations, all UB participants must meet the following criteria: Indicate an interest in attending college; Demonstrate academic need Qualify as Low Income and/or Potential First Generation College Graduate (neither parent has received a 4-year degree); Commit to remain active in UB until high school graduation Please complete this application and return with your child s Student Application to the address or fax number listed above. You may also return your completed application to your child s school counselor. All completed applications will be reviewed and eligible applicants contacted within 14 days. Thank you for your interest in the Upward Bound Project. Please call a UB project staff member at (269) if you have any questions or need additional assistance. Sincerely, Director, Upward Bound PART III UB Parent Application (To Be Completed by Parent/Guardian): Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 8

9 Student s Name: Current School & Grade Level: Mother s Name: Father s Name: Mother s Address: Father s Address: Mother s Home Phone Number: Father s Home Phone Number: Mother s Cell Phone Number: Father s Cell Phone Number: Mother s Work Number: Father s Work Number: Has either parent/guardian received a 4-year degree from a college or university? Yes No I certify that the information provided on this form is true and complete to the best of my knowledge. Parent/Guardian s Signature Date Income Information: For purposes of documentation, please provide a copy of your most recent Federal Income Tax Return. Make sure that it contains the names of your dependents and the Taxable Income for the current year. If you have not yet completed your tax return, send a copy of all W-2 forms and fill in as much of this form as possible, including signature, date and the total number of exemptions. Mail or fax ( ) a copy of your most recent tax form as soon as it is done. If you do not file a tax return, you will be required to provide another source of income verification before this application can be processed. Parent/Guardian Printed Name *Student s Name Number of Exemptions Including Yourself (Total number in your economic household): Did you, or are you planning to file a federal income tax return? Yes No If yes, what was your most recent taxable income? (Check which form was used and fill-in the taxable income.) IRS FORM 1040 Line 37 $ Or IRS FORM 1040A Line 21 $ Does your family receive assistance from any of the following sources? Yes No If yes, please send a copy of the award letter(s) for verification of assistance. Temporary Aid to Needy Families (TANF) Social Security Food Stamps Retirement Benefits Veterans Benefits Other: The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 9

10 Release of School Records for Western Michigan University Upward Bound Program Please complete the release form below. The Upward Bound staff will deliver this release form to your school. Dear School Administrator (from parent/guardian): As the parent/legal guardian of this student, I give my permission for him/her to participate in the Upward Bound program. I authorize the Upward Bound Program of Western Michigan University to access and/or receive copies of my student academic transcripts, grade reports, report cards, MEAP scores, and any other academic information and test results necessary to complete the program s application process. Please send a copy of my student s: Current transcript, and Scores for standardized achievement, diagnostic tests/assessments, and Parent Internet Viewer (MME) (MEAP) (ACT) (SAT) SEND TO: Western Michigan University Upward Bound Program 2211 Ellsworth Hall Kalamazoo, MI OR deliver to the Upward Bound staff OR Upward Bound mailbox in the mailroom at one of the following high schools (If applicable): Kalamazoo Central or Loy Norrix High School Parent/Guardian name (please print): Parent/Guardian signature: Date: Dear School Administrator (from student): I hereby consent for Upward Bound to access my school records and to collaborate with school personnel on my behalf. Student name (please print): Student signature: Date: PART III UB Parent Application (To Be Completed by Parent/Guardian): Division of Multicultural Affairs Office of Diversity and Inclusion revised 9/13/12 10

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